Aalok Ranjan Chaurasia. Health and Public Health Public Health in India Before the Colonial...

Public Health in India

Aalok Ranjan Chaurasia

Outline

Health and Public Health Public Health in India

Before the Colonial period During the Colonial period After the colonial period

Essential Public Health Functions Mortality transition in India

Health

The World Health Organisation defines Health (of an individual) as the state of complete physical mental and social well-being and not merely the absence of disease or infirmity.

World Health Organisation, however, does not define Public Health.

Death

Death, on the planet Earth, is inevitable.

A large number of deaths are premature.

A substantial proportion of deaths can be avoided.

Public Health is related to preventing premature and unavoidable deaths.

A Model of Health

Exposure to Risk Factors

Body resistance

Poor Health

Manifestation

Disease Condition

Disability Death

Public Health

If the disease condition is avoided, the probability or the chance of death or disability can be reduced.

Public Health is therefore described as the science and art of preventing diseases, prolonging life and promoting health (of individuals) through organised efforts and informed choices.

Public Health

Public Health deals with the group of people rather than individuals.

Dimensions of public health Health promotion Disease prevention Early diagnosis and prompt treatment Disability limitation Rehabilitation

Traditional Indian Approach

The Indian approach to health is enshrined in the concepts and principles of Ayurveda which means the ‘science of life’.

Ayurveda is one of the oldest system of health care in the World.

Ayurveda deals with both preventive and curative aspects of health.

Health defined by WHO is very similar to concepts of Ayurveda.

Western Approach

The western approach of avoiding diseases, death and disability, traditionally focused on personal hygiene and public sanitation during the 19th Century.

This approach, combined with better food availability, paid rich dividend in the developed countries in reducing morbidity and mortality.

Components of Public Health

Epidemiology Measurement of disease conditions in

relation to the population at risk. Statistics

Collection, presentation, analysis and interpretation of epidemiological data.

Health Services Services directed towards meeting the

health needs of the people.

Public Health before the Colonial Period

Little is known about public health activities before the colonial period.

Main stream system of health care was Ayurveda.

Home-based care appeared to be the dominant feature.

There appeared little organised efforts or institutional care to treat diseases and prevent deaths.

Public Health during the Colonial Period

Evolution of public health system during the colonial period followed the same path that was followed in Britain.

Public health efforts were focused largely on protecting British civilians and army cantonments.

Sanitation was given the top priority. Focus was also on early detection

and control of contagious diseases – cholera and plague.

Public Health during the British Period

Training and research Institutions in public health.

Public health legislation. Sanitary departments

Ascertaining local sanitary conditions. Vital registration. Monitoring disease trends. Vaccination programmes. Technical advice on control of epidemics.


Restriction of public health efforts to British civilians and military established was a major constraint.

Majority of Indian masses remained deprived of the dividends of these efforts.

At the time of Independence only 3 per cent households in India had toilets.

Water, drainage and waste disposal services were utterly lacking.


Although, public health efforts were restricted to British civilian and military establishment, they had impact on Indian masses. Mortality spikes were sharply reduced. Mortality from cholera and plague was

sharply reduced. Diseases like malaria and gastro-

enteritis continued to take heavy toll.

Public Health in Independent India

Evolution of public health care system in Independent India was shaped by two important factors: The Report of First Health Survey and

Development Committee (Bhore Committee) constituted during the colonial rule.

Emergence of modern medical technology for the prevention and control of diseases, especially communicable diseases.

Bhore Committee

Appointed in 1943. Recommended comprehensive

remodeling of health services. Integration of preventive and curative

health services at all levels. Hospital-based health care system. Development of primary health centres

in two stages. Training in Preventive and Social

Medicine.

Bhore Committee

The short-term plan A PHC for every 40000 population. PHC to be manned by 2 doctors, 4 PHN,

4 Midwife, 1 Nurse, and others. The long-term plan

A primary health unit for every 10-20 thousand population with 75 beds.

Secondary unit with 650 bedded hospital.

District unit with 2500 bedded hospital.

Medical Technology

Mass production of antibiotics. Availability of vaccines for diseases

having high mortality and disability rates Tetanus Diphtheria Pertussis (Whooping Cough) Measles Poliomyelitis


The recommendations of Bhore Committee and the availability of preventive and curative medical technology resulted in the evolution of hospital-based public health system.

The public health arrangements created during the colonial period were replaced by hospitals and health centres.

Public health services were merged with the medical services.


Bhore Committees recommendations were accepted only partially. One primary health centre for every 30

thousand population. Only 6 beds in each primary health

centre. Only one doctor. Truncated paramedical staff.

The situation has remained largely unchanged.


Since Bhore Committee, numerous committees were constituted to evolve the public health system.

Some of the recommendations of these committees were adopted; some were not by the government.

All committees retained the core of the model recommended by the Bhore Committee.


Mudalliar Committee(1962) Strengthen PHCs before establishing

new ones.▪ PHC should provide preventive, promotive

and curative services. Strengthen sub-divisional and district

hospitals. Creation of All India Health Services.

Chaddha Committee (1963) Malaria worker to function as

multipurpose worker.


Mukherjee Committee (1965) Separate staff for family planning

programme. Malaria activities to be de-linked from family

planning activities. Jungalwala Committee (1967)

A unified approach for all problems instead of a segmented approach for different problems.

Medical care and public health programmes to be put under charge of a single administrator.


Kartar Singh Committee Concept of MPW(M) and MPW(F). One PHC to catre 50 thousand population. Each PHC should have 16 SHC (3-3.5

thousand population). Shrivastav Committee

Creation of bonds of paraprofessional and semiprofessional health workers from within the community itself.

Development of a “Referral Services Complex.”


Bajaj Committee Formulation of National Medical & Health

Education Policy. Formulation of National Health Manpower

Policy. Educational Commission for Health Sciences. Health Science Universities in various states. Health manpower cells. Vocationalisation of education at 10+2 levels

as regards health related fields. Realistic health manpower survey.

Public Health System in India

A population based normative approach is adopted for establishing hospitals and health centres SHC – One for every 5000 (3000 in

hilly/tribal areas) population. PHC – One for every 30000 population

(20000 in difficult areas) with 4-6 indoor/observation beds.

CHC – One for every 80-120 thousand population with 30 beds.

Public Health System in India

The norms are for government institutions and are for the rural areas only.

For the urban areas, no norms have been defined.

Nearly all government civil and district hospitals and most of the CHCs are located in the urban areas.

No information is available about the private health system.

Public Health System in IndiaInstitution Refere

nceNumber

SHC 2007 145272 More than 6 SHC for each PHC, on average

PHC 2007 22370 More than 5 PHC for every CHC, on average

CHC 2007 4045

Rural hospitals

2007 6298

Beds in rural hospitals

2007 142396 About 23 beds per rural hospital

Urban hospitals

2007 2774

Beds in urban hospitals

2007 324206 About 117 beds per urban hospital


One fall out of the hospital-based public health approach was the neglect of public health legislation.

A Model Public Health Act was drafted in 1950 by the Government of India.

It was revised in 1987. This Act is yet to be adopted by any

of the constituent state of the country.


The hospital-based public health system led to the medicalisation of the system.

The focus has been on medical services. Public health services have largely been

neglected. Poor public health services result in high

cost of illness, debility and death. The main sufferer are the people,

especially the poor and deprived.


The epidemiological and statistical dimensions of public health have been grossly neglected.

Lack of epidemiological and statistical database affected public health planning.

In the absence of necessary information, planning reduced to a normative, mechanical exercise, often out of context to people’s needs.


The problem gets complicated because of social, economic, cultural and environmental diversity that leaves normative planning virtually redundant.

Decentralisation of the health system could not succeed because of the lack of epidemiological and statistical information necessary for planning for public health services.


Public health in India is ‘hospitalised.’ Health planning is concerned more

with the health of the health care delivery system (hospitals and health centres) then the health of the people.

The remedy was sought in terms of specific National health and disease control programmes.

There are numerous such programmes.


Reproductive and child health programme.

National tuberculosis control programme.

National malaria control programme. National blindness control

programme. National water born disease control

programme. National leprosy eradication

programme. National iodine deficiency control

programme.


All National disease control programmes are implemented through the existing government hospitals and health centres.

Over the years, a campaign approach has been evolved to implement many of the national health and disease control programme.

Successful campaigns have often been followed by unsuccessful maintenance.


Focus on medical services. Neglect of public health services. No modern public health regulation. Lack of systematic planning. Poor sustainability of public health

efforts. Absence of epidemiological and

statistical skills at district and below district level.

No micro-level planning, no public health action.

Essential Public Health Functions

Essential Public Health Functions in India

Health situation

Epidemiological surveillance

Health promotion

Regulation

Participation

Policy and planning

Evaluation

Human resources

Quality

Research

Management capacity

Emergencies and Distasters

0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8

Mortality Transition in India

45

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55

60

65

70

75

80

1973 1978 1983 1988 1993 1998 2003

ObservedVery fastFastMediumSlowVery slow

45

50

55

60

65

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75

80

1973 1978 1983 1988 1993 1998 2003

ObservedVery fastFastMediumSlowVery slow


Widespread existence of preventable diseases and deaths is a disgrace to the society which tolerates it.

Thank You

Aalok Ranjan Chaurasia. Health and Public Health Public Health in India Before the Colonial...

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